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Senior Pharmacy Coordinator
Highmark Health. Provide front-line staff guidance and ensure effective, efficient delivery of Pharmacy call center services .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in pharmacy prescription claims processing and formulary management, ensuring compliance with state and federal regulations while effectively communicating with providers and members. Proficient in evaluating drug authorization requests and maintaining accurate documentation within regulatory timelines.
Highest-signal resume keywords
Pharmacy Prescription Claims ProcessingFormulary ManagementPrior Authorization Criteria ReviewHIPAA ComplianceInterpersonal Communication Skills
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims ProcessingDrug Authorization ReviewMedical Necessity EvaluationCoordination of BenefitsFormulary TerminologyMedication KnowledgeOnBaseArgus IPNSData Security ComplianceRegulatory Adherence
Soft Skills
Attention to DetailOrganizational SkillsListening SkillsTeam CollaborationProblem Solving
Tools & Technologies
Microsoft OutlookMicrosoft WordOnBaseArgus IPNS
Certifications & Qualifications
Pharmacy Technician Certification
Industry Keywords
Managed CareMedicaid Drug BenefitMedicare Drug BenefitDrug Claim EditsPoint-of-Sale Prescription Claims
About the role
Key responsibilities & impact- Provide front-line staff guidance and ensure effective, efficient delivery of Pharmacy call center services
- Serve as first-line reviewer for adherence to state and federal drug benefit designs
- Respond to physician and pharmacy network provider inquiries regarding oral, injectable, and infusion medication requests, drug claim edits, and prior authorizations
- Review member claims history and define medical necessity for non-formulary and prior authorization medication exception requests
- Educate and assist pharmacy network providers with denied point-of-sale prescription claims and coordination of benefits procedures
- Communicate with providers to address provider and plan member needs
- Interact with staff to implement processes and solve problems
- Evaluate and direct daily departmental workflow
- Prioritize drug authorization and denial requests
- Review prior authorization criteria for drug products
- Recommend staffing adjustments to maintain efficiency and productivity
- Ensure compliance with call center turnaround requirements associated with DPW/CMS regulations
- Evaluate non-formulary drug exception requests before approval, authorization, or claim override
- Search member claim histories and recommend formulary alternatives
- Contact physician network providers to obtain additional information
- Consult clinical pharmacists as needed
- Document authorizations and denials accurately and within regulatory timelines
- Populate authorization and denial fields in OnBase
- Enter authorizations into Argus IPNS for claim adjudication
- Identify and report improper coordination-of-benefits billing practices through paid-claims review
- Participate as pharmacy representative in onsite member appeals and grievance sessions
- Serve as a technical staff resource
- Complete other assigned duties
Requirements
What you’ll need- High school diploma or GED
- Experience in pharmacy prescription claims processing/submission/payment
- Associate degree (preferred)
- Pharmacy technician certification certificate (preferred)
- Experience working in a managed care medication formulary management environment (preferred)
- Working knowledge of retail pharmacy and/or third party prescription processing (preferred)
- Strong background and understanding of medications and formulary terminology (preferred)
- Familiarity with multiple Medicaid drug benefit design offerings and rules/regulations across multiple states
- Familiarity with Medicare drug benefit design offerings and applicable federal rules/regulations
- Excellent computer skills, including Microsoft Outlook, Word, and OnBase
- Excellent interpersonal, communication, and attentive listening skills
- Strong organizational skills and attention to detail
- Ability to work well with others
- Ability to work in a fast-paced, multi-task environment
- Compliance with HIPAA, data security guidelines, company policies, applicable laws, rules, and regulations